Please utilize this form to report any incidents that may be related to bullying at Klinger Middle School.
What is your name?
I am a...
What was the victim's name?
What was the aggressor's name?
I saw this myself
Someone told me about this
People are talking about this
Someone sent this to me
Who were the witnesses (names if possible)?
If cyber, do you have any evidence (example, screenshots, photos, videos, etc.)
If you have evidence, please explain what you have.
Was this physical, verbal, or cyber?
Other Social Media
Physical and verbal
Physical and Cyber
Verbal and Cyber
Multiple Types of Cyber
Where did this occur? (if this was a cyber event, where was the post, message, etc. received).
Out of school
On the bus
In the cafeteria
In the classroom
In the hallway
In the bathroom
When did this occur? (Date and time if possible)
Have you told any staff at Klinger about this? If so, who?
Please provide your phone number or email address if you would like to be contacted.
If there is anything else that you feel is important for Kilnger staff to know about this situation or incident, please explain.
Send me a copy of my responses.
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